OUTCOMES RESEARCH IN REVIEW
Forced Smoking Cessation Is Insufficient to Promote Prolonged
Abstinence
Clarke JG, Stein LAR, Martin RA, et al. Forced smoking abstinence: not enough for smoking cessation.
JAMA Intern Med 2013;173:789–94.
Study Overview
Objective. To examine the efficacy of the Working Inside
for Smoking Elimination (WISE) intervention to decrease
relapse to smoking after release from a smoke-free prison.
Design. Randomized controlled trial.
Setting and participants. The study was conducted in a
large state correctional facility in the northeastern part of
the United States. The facility had a campus-wide smoking
ban, which prohibited use of any tobacco products on site
by inmates or staff. Participants were eligible for screening
if they were sentenced male or female individuals who were
to be released within 8 weeks. Screened participants were
eligible if they were 18 years or older, smoked ≥ 10 cigarettes per day prior to incarceration, and spoke English.
The final sample included 247 participants. Participants
were randomly assigned to receive the WISE intervention
or to watch educational videos on health-related topics
other than smoking cessation (control group). Randomization was stratified by sex, number of cigarettes smoked
prior to incarceration, and post-release smoking plans.
Intervention: The WISE intervention consisted of 6
weekly sessions: sessions 1 and 6 comprised motivational
interviewing (MI) and sessions 2 through 5 comprised
cognitive behavioral therapy (CBT). The MI sessions
focused on developing discrepancy, self-efficacy, and
personal choice, whereas the CBT sessions focused
on triggers to smoking and developing skills to counter these triggers. Participants also received brief telephone counseling sessions at 24 hours and 7 days after
release.
Outcome measures: Prolonged abstinence was defined
as having a negative urine cotinine evaluation and a
self-report of no smoking in the previous 7 days. Participants were asked to complete an assessment at baseline
and at 3 weeks after release. Participants who were abstinent at 3 weeks were invited to complete a 3-month
assessment and urine cotinine evaluation. The assessments were conducted using audio computer-assisted
self-interviewing technology. The assessment included
demographics, smoking history and dependence, subjective stress, presence of smoking-related chronic diseases,
depression, and receipt of drug treatment. Participants
were asked whether they had an intention to remain
tobacco-free after release, and were categorized as “plans
to smoke after release” or “plans to not smoke after
release.”
Outcomes Research in Review Section Editors
Jason P. Block, MD, MPH
Brigham and Women’s Hospital
Boston, MA
Melanie Jay, MD, MS
NYU School of Medicine
New York, NY
Ula Hwang, MD, MPH
Mount Sinai School of Medicine
New York, NY
Maya Vijayaraghavan, MD
University of California, San Diego
San Diego, CA
Kristina Lewis, MD, MPH
Kaiser Permanente Center for
Health Research
Atlanta, GA
William Hung, MD, MPH
Mount Sinai School of Medicine
New York, NY
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Vol. 20, No. 7 July 2013 JCOM 297
OUTCOMES RESEARCH IN REVIEW
Main results. At baseline, intervention groups did not
differ significantly on demographics, smoking variables,
depression, or stress. Of the 247 participants, 228
(92.3%) completed the 3-week, post-release assessment.
Of the 122 participants who were randomized to the
WISE intervention, 83.3% completed all 6 sessions. At
3-week follow-up, 25.4% of the participants randomized
to the WISE intervention were abstinent from smoking
compared with the 7.2% of those in the control group
(P < 0.01). Compared with smokers, those who were
non-smokers were more likely to be Hispanic (33.3% vs.
17.6%, P < 0.05), have attended a substance use treatment program in prison (63.2% vs. 47.3%, P < 0.1), and
planned to not smoke upon release (62.5% vs. 46.1%,
P < 0.1). In multivariable logistic regression analysis,
persons enrolled in the WISE intervention had sixfold
greater odds of being abstinent at 3 weeks compared
with the control group (adjusted odds ratio (AOR) 6.6,
95% CI 2.5–17.0). Other factors associated with 3-week
abstinence included not smoking for > 6 months (AOR
4.6, 95% CI 1.7–12.4), being Hispanic (AOR 3.2, 95%
CI 1.1–8.7), intention of not smoking after release (AOR
1.6, 95% CI 1.2–2.3), and receipt of in-prison drug
treatment (AOR 1.9, 95% CI 0.8–4.6). Of the 40 participants who were abstinent at 3-week follow-up, 11.5%
from the intervention group and 2.4% from the control
group were abstinent at 3 months. In the adjusted Cox
proportional hazards model, the first day after release was
found to be the highest-risk day for relapse to smoking.
After day 1, relapse to smoking declined sharply in the
intervention group compared with the control group.
The control group had 1.75 times the risk of relapsing
to smoking compared to the WISE intervention group
(hazard ratio 1.75, P < 0.001).
Conclusion. Forced smoking abstinence due to a prison
smoke-free policy is insufficient to promote sustained cessation after release into the community. A behavioral intervention accompanied by the smoke-free policy prior to
release may improve smoking cessation in the community.
Commentary
There are approximately 2.3 million people incarcerated
in federal, state, and local correctional systems in the
United States. Individuals who experience incarceration have risk factors that lead to poor health outcomes:
mental health and substance use disorders are common
298 JCOM July 2013 Vol. 20, No. 7
among this group, as is smoking [1]. The prevalence of
smoking among individuals experiencing incarceration
ranges between 60% and 70% [2,3]. Over the past 3
decades, correctional facilities have increasingly adopted
strict smoke-free policies to reduce harms from exposure
to secondhand smoke. A national survey of federal and
state correctional facilities in 2007 found that approximately 60% of prisons had implemented campus-wide
smoking bans (ie, no smoking in indoor or outdoor areas
of the facility) [4]. The majority of these facilities did
not offer smoking cessation treatment [4]. An evaluation
of these policies showed that while smoke-free policies
reduced exposure to secondhand smoke, they were insufficient to promote sustained smoking cessation, as the
majority of individuals resumed smoking after release
from a smoke-free correctional facility [5]. Moreover,
inmates’ lack of access to health care after release into
the community poses challenges to seeking smoking
cessation care in the community, and may contribute to
relapse to smoking. Thus, the current study, which is directed toward preventing relapse to smoking after release,
is timely and fills an important gap in the field of tobacco
intervention research for vulnerable populations.
Individuals who participated in the WISE intervention had abstinence rates of 25.4% at 3 weeks and
11.5% at 3 months compared with the control group,
where abstinence rates were 7.2% and 2.4%, respectively.
Previous studies have highlighted the importance of a
smoke-free policy in changing norms around smoking
and in promoting smoking cessation [6]. Individuals
in the control group who achieved abstinence may have
done so because of the smoke-free policy. However,
the effect of the smoke-free policy alone on sustained
cessation was significantly lower than that of the policy
accompanied by a behavioral intervention. These results
highlight the benefits of introducing behavioral interventions for smoking cessation in correctional facilities
that have implemented smoking bans. The focus of
these intervention could be on improving self-efficacy
to stay abstinent and to prevent triggers to smoking
relapse after release into the community.
Although abstinence rates were high in the intervention group, the majority relapsed to smoking within 3
weeks of release into the community. The relapse rate
was highest the day after release for both intervention
and control groups. These results highlight the importance of continuing smoking cessation care while
in the community to maximize efforts made toward
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OUTCOMES RESEARCH IN REVIEW
smoking cessation during incarceration. In 2014, the
Patient Protection and Affordable Care Act (ACA) will
expand Medicaid coverage to single individuals younger
than 65 years of age who have incomes up to 133% of
the federal poverty line. Many individuals who experience incarceration will be newly eligible for Medicaid
and the smoking cessation services offered through
Medicaid upon release into the community. Ensuring
a seamless transition to health insurance, and appropriate discharge planning and referrals to patient-centered
medical homes, may enable incarcerated individuals to
receive continued treatment for smoking cessation after
leaving the correctional facility.
The study had several limitations. The duration of
follow-up for the intervention was short, and it is possible that the effects of the intervention could wane over
time. The study was restricted to sentenced individuals,
who generally have prison stays lasting 1 year or longer.
Thus, the results may not be generalizable to individuals staying in jails, where average length of stay is < 3
months. As these individuals are exposed to smoke-free
policies for shorter periods of time and have shorter
lengths of forced abstinence, their rates of relapse may
be higher than those observed in prisons. Thus, interventions may need to be more intensive and initiated at
the time of entry into the facility for those with shorter
stays in prisons or jails. Despite these limitations, this
study is among the first to demonstrate the efficacy of a
relapse prevention intervention for individuals who are
about to be released into the community from a smokefree correctional facility.
Applications for Clinical Practice
The high rates of smoking and smoking-related morbidity
and mortality among individuals who experience incarcera-
tion highlight a need for interventions to address tobacco
use in this population. Most correctional facilities in the
United States have implemented smoke-free policies, and
these policies have been associated with reduced exposure
to secondhand smoke and increased smoking cessation during incarceration. Moreover, these policies play a significant
role in changing norms around smoking by making environments less permissive of smoking. However, the high
rates of relapse after release into the community suggest
that smoke-free policies alone are insufficient to promote
sustained cessation. The results of the current study support
the use of behavioral interventions in concert with smokefree policies to prevent relapse to smoking after release from
a smoke-free correctional facility. The results highlight the
need for continued access to smoking cessation treatment in
the community for the majority of individuals who resume
smoking after release from a smoke-free correctional facility.
—Maya Vijayaraghavan, MD, MAS
References
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2. Binswanger IA, Krueger PM, Steiner JF. Prevalence of
chronic medical conditions among jail and prison inmates
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3. Kauffman RM, Ferketich AK, Murray DM, et al. Tobacco
use by male prisoners under an indoor smoking ban. Nicotine Tob Res 2011;13:449–56.
4. Kauffman RM, Ferketich AK, Wewers ME. Tobacco policy
in American prisons, 2007. Tob Control 2008;17:357–60.
5. Lincoln T, Tuthill RW, Roberts CA, et al. Resumption of
smoking after release from a tobacco-free correctional facility. J Correct Health Care 2009;15:190–6.
6. Mills AL, Messer K, Gilpin EA, Pierce JP. The effect of
smoke-free homes on adult smoking behavior: a review.
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Copyright 2013 by Turner White Communications Inc., Wayne, PA. All rights reserved.
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